Articles for therapists and counsellor about CBT - Cognitive Therapy. These posts are intended to help the beginning CBT practitioner and also provide food for thought for experienced cognitive therapists. Provided by UKCP Central London therapist and accredited CBT practitioner and supervisor Tim LeBon.

Wednesday, 25 November 2015

This excellent workshop wasn't intended as a complete training in DBT, but rather as a way to understand how an experienced practitioner could take parts of the DBT model and incorporate it into their practice. It worked for me! Here are the top 10 things I learnt from the course

1) DBT is Dialectical

Dialectical means accepting and working with opposites and apparent contradictions

There is a thesis, an antithesis and then a synthes which includes truth from both.

For example, if thethesis is "I need to change!".

and the antithesis is "I can't change".

thesynthesis could be "Change is difficult. What I have tried so far hasn't worked. I need to work on skills to change, even though this will be difficult".

If a client wants to practice midfulness (the thesis) but has a cold and says "I cant do mindfulness today because I have a cold" then as a therapist you might helpful suggest (the synthesis) "Your cold presents you with a great opportunity to practice mindfulness when its harder"

2) DBT is Behaviorial

The focus is on behaviours that need to be changed for the client to achieve their goals. This provides a very clear focus and can make the complicated and complex much simpler
The therapy focuses on

What am I doing causing me and others problems and what can I do differently?

Below is a summary of some behavioural principles which can help guide a skilful therapist

Form a plan to change unhelpful behaviours

Get whole lot of possible solutions

Give them skills ask them to choose like a smorgasbord then ask which appeals most

Look at obstacles and how to overcome them

Shape and reward desired action - if they have done something positive, praise this

3) DBT is Skills-based

Forming a plan is a good start, but many people don't have the skills to carry this out effectively. There is a large element of skills training in DBT and this is usually done in Skills groups

where participants learn to decrease problematic and unskillful behaviours.

4) A possibly lengthy assessment phase

DBT is a big investment for both client and therapist. It is fitting then that some time is given for the potential client to think about whether to commit to DBT.
A Contract usually a year involving a lot. Asssement will explore motivation and behaviours they want to change. This phase can last up to 6 weeks

5)Telephone coaching is part of the deal

In a DBT group, the client is offered telephone coaching when they need it. This is specifically for help when they are in crisis. The client will form a crisis plan which they have with them
If they ring, you go through the crisis plan with them
"Get them to breathe then walk through plan"

6)Validation and Acceptance of the client

Although change is the desired outcome, validation is an extremely important prerequisite for change

These range from showing an interest, to validating their emotions and behaviours "It's normal to feel anxious before coming to see a therapist." You are accepting the person, but that doesn't mean you are endorsing unhelpful behaviours.

7) Use of Chaining as a formulation method

This is similar but not identical to CBT's "Hot Cross Bun" or "maintenance cycle" formulation is called "Chaining" in DBT.

Chaining is actually fairly straightforward and involves the following steps :-
Ask

When did you first know that the problem behaviour would arise?

If you were in situation again what would you do differently?

What stopped you this time?

What made you vulnerable at this time

What happened when you stopped

What are the consequences?

What can we learn from this?

Then ask them to describe the sequence as if telling an actor how to play the part. It needs to be spefific. You are finding out the chain of antecedants, behaviours and consequences in terms of thoughts, feelings, urges and behaviours.

8) The Role of individual sessions

A lot of the skills learning takes place in the group sessions, but individal sessions are important too. In these you make list of target unhelpful behaviours to reduce

In each session work through list in each area hierarchically

They bring in diary/ Your job is to keep them "on the hook"

9) Wise Mind

DBT makes the helpful distinction between Logical. Emotional and wise mind
Logic is great - but what it would be like to be just in logical mind, like Mr Spock?
We would lose a large part of what it is to be human, what motivates us and what makes us individual. Fear keeps us safe. Anger stops people treating us like a doormat

Yet emotions can get us into a lot of trouble.

We need emotions - but in moderation

Wise mind can moderate emotions, its the synthesis of logical mind and emotional mind.

Here is an exercise that might help you locate your own wise mind
Think of a dilemma

Start with facts and logic

Then think about the emotions and desires connected with the dilemma

Imagine falling down a well taking all the facts and feelings with you. At the bottom is
a trap door. Through this trap door is your wise mind, which takes into account logic and feelings. Go through the trap door? What does wise mind tell you is right for you?

Wednesday, 18 March 2015

This is the third and final part of a series of articles about three ways of doing CBT with a hypothetical client, "John".

John comes to CBT because of his depression. He is a 40 year old who has recently been made redundant. He is worried about getting a job again and his redundancy has also caused tension in his marriage. When questioned about how he spends his time now, he says he gets up late, intends to look for jobs but ends up doing very little. He feels demotivated, discouraged and, at times, hopeless. He is having trouble sleeping and hints that he may be using drinking to cope with his difficulties. At times, he says, he wonders if he will ever get a job again. He sees his redundancy as meaning that he is a failure. He talks in a flat, slow monotone. As he talks, he is becoming more sad and more hopeless.

In the first article, counsellor A had a short car-crash session, in the second article counsellor B if anything did even worse. Yet both included good evidence-based CBT ideas ... Now we will see how counsellor C takes a somewhat different approach so the session lasts a bit longer ...

How to do CBT:
Counsellor C with John

C1: Good to see you again, John, I can see from the PHQ9 scores you filled in
whilst you were waiting that it’s been quite a tough week but there’s been some
improvement. Is that how it seems to you?

J1: I didn’t realise
there had been improvement. Still feels pretty grim at times to be honest

C2: Sorry to hear that – shall we put that as one of the
items on our agenda for today?

C6; Now we have an ongoing agenda item – review homework –
so we’ll do that first as usual. I’d also like to add to the agenda –“pros and
cons of being active” – is there anything else you would like to add?

C7: OK, that’s something we should definitely add to the
agenda (writes down “Am I wasting counsellor’s time?”). We’ll look at that more fully later, but can you just say a little now about why
you think you are wasting my time?

J6: I still haven’t got a job. I still waste most of my
time. I’m a waste of space ….

C8: It sounds like that’s definitely an important thing for
us to look at. We’ve got 4 things on our agenda – review homework, Address
feeling grim, pros and cons of being active and am I wasting counsellor’s time.
I’m wondering whether that might be a good order to look at things? I’m
thinking that later in the session we might have a better idea about how useful
this process is for you.

J7 : That makes sense.

C9: So, how did you get on with the homework?

J8: (Gets sheet out of pocket) Here it is.

C10: Would you like to talk me through it?

J9:OK …Well, on Wednesday I didn’t feel great, I didn’t
really feel like going out but I had a
letter to post so went into town and actually it looks like my mood did go up
from a 4 to a 5. Then the rest of the day wasn’t so bad. Thursday was bad
though. I woke up feeling totally lacking in energy. I stayed in bed .. didn’t get up until 200.
Then it felt like it was too late to do anything. Then later in the evening I
felt even worse, thinking “I’ve wasted the day, I’m never going to get better.”

C11: And what happened to your mood on Thursday?

J10: It started at 3 – then went down to a 2 in the evening.
Not great.

C12: No, it doesn’t sound like a good day at all. Still, hat
was a great effort to fill the forms in even though you were feeling so low.
Well done. Shall we look at the two days together and see what we can learn
from them?

J11: Sure

C12: So on Wednesday, you didn’t feel like going out, but do
did and then you felt better. What can we learn from that?

J12: Maybe that being active helps, but that sometimes we
don’t feel like being active.

C13: Exactly. So should we always do what we feel like
doing?

J13: No, because actually
I felt better after I did what I didn’t feel like doing

C14: That’s a very important insight you’ve captured there,
John. We often do feel better when we are more active. But when depressed we
don’t feel like being active. So what have we got to do to lift the depression?

J14: Be active even when we don’t feel like it?

C15: Exactly. How would you feel about trying that as part
of the homework for next week?

J15: I’ll try.

C16: Let’s write it down. “Last weeks’ homework suggests
that it will help to be active even when I don’t feel like it.” What else do we
need to record?

J16: Maybe how I feel about being active at the time?

C17: Right, so let’s add another column to your record sheet
– “How I feel about being active”. How does that sound? Can you imagine recording
this?

J17: Yes

C18: Do you think it might be helpful?

J18: Yes

C19: OK – just to make certain, let’s see how that might
have panned out on Thursday. If you’d been tracking your thoughts then as well,
what would you have written down?

J19: Let me think. Probably “I’ve no energy so I’ll stay in
bed?”

C20: Bearing in mind what we’ve just learnt, what do you
think now?

J20: Even though I don’t feel like being active, if I do
I’ll feel better

C21. Great. So I’m wondering if we need another column, like
this (Adds another column –“more helpful thought.”) How does that look?

J21: Looks good – not sure though if it will work though if
I am feeling as low as I did on Thursday.

C22: Is it worth trying?

J22: Yes, it’s worth a try.

J23: How are you feeling now about our work today so far?

J22: Good

C23: Me too.. Shall we take stock. So far today we’ve reviewed
the homework, and seen that on the day when you are more active, you feel
better. So we have set up a homework task next week where you notice negative thoughts
telling you not to be active, and do your best at answering back to them and
then being active – again recording how you feel afterwards. Have I missed
anything?

J23: No

C24: So shall we move
on to the other agenda items. We had “wasting
my time” –do you still think you are wasting my time?

J24; No, not nearly so much

C25: Good, neither do I. Shall we move on to the next item
on our agenda?

Friday, 13 March 2015

People always comin' up to me and askin' "Dolly, what's your secret? With all you do, your attitude Just seems to be so good How do you keep it?" Well I'm not the Dalai Lama, but I'll try To offer up a few words of advice

Chorus:

You better get to livin', givin'
Don't forget to throw in a little forgivin'
And lovin' on the way
You better get to knowin', showin'
A little bit more concerned about where you're goin'
Just a word unto the wise
You better get to livin'

A girlfriend came to my house
Started cryin' on my shoulder Sunday evening
She was spinnin' such a sad tale
I could not believe the yarn that she was weavin'
So negative the words she had to say
I said if I had a violin I'd play

I said you'd better get to livin', givin'
Be willing and forgivin'
Cause all healing has to start with you
You better stop whining, pining
Get your dreams in line
And then just shine, design, refine
Until they come true
And you better get to livin'

Your life's a wreck, your house is mess
And your wardrobe way outdated
All your plans just keep on falling through
Overweight and under paid, under appreciated
I'm no guru, but I'll tell you
This I know is true

You better get to livin', givin'
A little more thought about bein'
A little more willin' to make a better way
Don't sweat the small stuff
Keep your chin up
Just hang tough
And if it gets too rough
Fall on your knees and pray
And do that everyday
Then you'll get to livin'

The day we're born we start to die
Don't waste one minute of this life
Get to livin'
Share your dreams and share your laughter
Make some points for the great hereafter

Thursday, 12 March 2015

This link will very likely expire in which case check out John Finnemore's Souvenir ProgrammeSeries 2 Episode 1

Episode 1

John Finnemore's Souvenir Programme,Series 2 John Finnemore, the writer and star of Cabin Pressure, regular guest on The Now Show and popper-upper in things like Miranda and Family Guy, records a second series of his hit sketch show.

The first series was described as "sparklingly clever" by The Daily Telegraph and "one of the most consistently funny sketch shows for quite some time" by The Guardian. It featured Winnie the Pooh coming to terms with his abusive relationship with honey, how The Archers sounds to people who don't listen to the Archers and how Dr Jekyll and Mr Hyde decided whose turn it was to do the washing up.

This episode doesn't feature any of those things, but it does feature an awkward celestial relationship, surprisingly easy contract negotiations, and a trailer for a film about the only mode of transport that hasn't had a film made about it yet.

John Finnemore's Souvenir Programme is written by and stars John Finnemore. It also features Margaret Cabourn-Smith, Simon Kane, Lawry Lewin and Carrie Quinlan. It is produced by Ed Morrish.1 of 6

Monday, 2 March 2015

To get away from an over-clinical, unfriendly caricature that CBT is sometimes associated with, it can be helpful to make CBT more human. One way of doing this is to mention songs that reflect CBT principles or ideas. Here are a few I have used

Another old classic - illustrates "how you feel affects how you think" principle. When we are depressed, we paint everything black. This song can help the client feel understood - and perhaps provide some distancing from this unhelpful strategy

I've mentioned this song to clients with social anxiety - don't care what other people think, hold yuor head up. One client turned it into a helpful mantra.

4. Fans of The Sopronos might remember with affection Tony's lamenting that he wish he was more like the Happy Wanderer of the song. There's plenty of evidence that exercise can help overcome low mood, and this song coud link with behavioural activation in general.

5. Here's one that you won't find in the charts - Windy Dryden's classic renditioning of Moves Like Jagger Dryen

Sunday, 1 March 2015

You've probably seen the debate about "The Dress" on social media and the intenet.What colour do you see the dress above as now?
Is it black and blue? Is it white and gold? Perhaps, like me, one time you see it one colour, and then when you return to it it looks different.

these help create doubt about us being so certain that how we see things is necessarily how they really are. Thoughts are not facts. That's a useful idea to convey to the client in CBT. For example:-

"At the moment you think the future is hopeless"
"You feel that you need to check those switches"
"You believe that when your boss asked for a meeting it means you are in trouble2

Each of these ideas are interpretations, and in CBT the client learns that they are not facts. They may not be either the most accurate way of looking things or the most helpful.Optical illusions are a nice way of making the point; how we see things isn't necessarily how they really are.

The interesting thing about the dress, more so than the duck rabbit, is that when we see it as black and gold, its actually hard to see it as white and gold - and vice-versa. This is often true when people are very depressed, ramped up through OCD. The message here is

At the moment you see things one way and it may wekk be hard to see it another way. As with that dress that you may have seen on the internet, could it be that there is another way of looking at your negative thoughts.

If the client answers "yes" you can then add - so what does that mean about how you should treat some of your negative or unhelpful thoughts? If they answer "It means that I should treat them with some caution, as if they are just thoughts rather than the facts they claim to be" then you have socialised your client into an important CBT principle